| NPI | 1306343884 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: CO PTL.0020874) |
| Additional Taxonomies | 225700000X Massage Therapist (Licence: CO MT.0018705) |
| Enumeration Date | 2018-04-10 |
| Last Update Date | 2025-10-14 |